Brookview Healthcare Center

In the surveyor’s words

From the most serious findings on record at Brookview Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF684Mar 27, 2025

  Based on resident interview, medical record review, hospital record review, staff interview, and policy review, the facility failed to ensure residents received timely treatment for constipation. This resulted in actual harm after Resident #14 had no bowel movement (BM) for seven days in the facility and was admitted to the hospital the following day with abdominal pain and was found to be impacted with stool. This affected one (#14) resident reviewed for bowel movements. The facility census was 72. Findings include: Review of the medical record for Resident #14 revealed an admitted [DATE] with diagnoses of constipation, anxiety, and generalized abdominal pain. […]

• Actual harm, isolatedF689Jan 4, 2021

  Based on observations, medical record review, review of hospital records, staff interviews, review of the National Institute of Health United States National Library of Medicine/Medline Plus website, review of the National Institute of Standards and Technology website, and review of facility policy, the facility failed to ensure a resident's environment was free from accident hazards to [MEDICAL CONDITION] two (#01 and #02) of two residents reviewed for burns. This resulted in Actual Harm for Resident #01 and Resident #02 when Resident #01 was discovered with her feet against the electric heater which caused second and third [MEDICAL CONDITION] and Resident #02 sustained [MEDICAL CONDITION] her right shoulder and back when she was found lying beside the electric baseboard heater. […]

• No harm, potential for more than minimal, widespreadF812Aug 1, 2022

  Based on observation, staff interview, and policy review, the facility failed to ensure appropriate sanitation when serving meals and failed to keep pureed meat at a safe holding temperature to potentially prevent foodborne illness. This had the potential to affect 62 of 62 residents. The facility census was 62. Findings include: 1. Observation on 07/25/22 at 11:12 A.M., of Assistant Dietary Supervisor (ADS) #467 checking the holding temperature of pureed fish revealed the temperature of the fish on the holding steam table was 120 degrees Fahrenheit. Interview of ADS #467, at the time of the observation, verified the pureed fish was 120 degrees. […]

• No harm, potential for more than minimal, widespreadF880Aug 1, 2022

  Based on observation, staff interview, infection control log review, [CONDITION(S)] risk assessment review, review of personnel files, and review of a facility policies, the facility failed to monitor for trends and patterns of infections in the facility based on facility policy, failed to sanitize hands and wear appropriate personal protective equipment (PPE) during resident care interactions, and failed to ensure the facility followed their [CONDITION(S)] risk assessment in monitoring staff for potential [CONDITION(S)] infections. This deficiency had potential to affect 62 of 62 residents residing in the facility. The census was 62. Findings include: 1. […]

• No harm, potential for more than minimal, patternF759Aug 1, 2022

  Based on observation, staff interview, medical record review, and review of a facility policy, the facility failed to ensure medications were administered as ordered. This affected five (#2, #12, #14, #56, and #59) of five residents observed during medication administration. A total of 15 medications errors were observed out of 28 medications administered which resulted in a medication error rate of 53.57 percent (%). The census was 62. Findings include: 1. Review of Resident #56's medical record revealed an admitted [DATE]. […]